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Good evening and welcome to Doc Talk Live at Matthews Art Center. Thank you for joining us tonight for our conversation on vein health. We're pleased to welcome Dr. Nicholas Czosnyka, a general surgeon from Spearfish Clinic, who will be sharing information about vein ablation, a minimally invasive treatment option for varicose veins and chronic venous insufficiency. So many people live with leg pain, swelling, or visible veins without realizing there are effective, minimally invasive treatment options available. Dr. Czosnyka will explain how vein ablation works, who may benefit, and what patients can expect. Please join me in welcoming Dr. Czosnyka.
Thank you very much. And thanks for coming out to hear a little bit about vein health and treatments for varicose veins. So, you know, the first thing I'll start by saying is varicose veins are extremely common, right? And when we talk about varicose veins, this is a spectrum. You probably noticed when you were twenty-five, you had a small spider vein on your leg that you didn't have when you were ten. And maybe as time has gone on, pregnancies, working, standing for long hours, people tend to develop larger varicose veins. And so when you talk about big varicose veins that you could see across the room, maybe only twenty percent of people have something like that. And then if you talk about a small spider vein that seems to be getting bigger, or maybe your ankles getting a little darker or something like that, that's a large percentage of people, maybe somewhere eighty to ninety percent of people have some type of vein that's growing in size or prominence. And so the bottom line is it's extremely common. But when we talk about varicose veins, especially in the context of intervening and treating them potentially with procedures, we need to really be questioning, well, what are we treating? The most important factor when it comes to assessing a patient's need for varicose vein treatments is their symptoms. Because if we don't have a symptom that we're making better, unfortunately the desire to have them not be there isn't generally what is considered a good medical indication to intervene. And so the symptoms people often have, some are common sense. If the vein's bulging and hurts, if the vein is bleeding, that makes sense. But more commonly, people have things like swelling, aching, edema, or the lower leg just gets a little bit bigger. There can be cramping at night, there can be restless leg at night, there can be discoloration of the skin, or even in worse cases there can be wounds that don't heal, what somebody might call an ulcer. And so there are lots and lots of very common symptoms that people may be living with that they're chalking up to, I'm just tired, or I've just been on my feet all day. And so when we meet for the first time, the big question I'm asking is, well, what are we trying to make better? And so people might have a varicose vein and this one varicose vein hurts or is problematic. Maybe it's right next to your knee or it's right on the back of your calf and this one spot is what hurts. But like we kind of mentioned in the intro, varicose veins are just one part of a bigger concept. And that's venous insufficiency. So if you think about how blood travels through your body, you've got your heart pumping, pushing blood through your arteries, getting blood out to all your tissues. And then your veins are the return pathway. And so your arteries are very dynamic. They're muscular, they stretch and they're very strong. They don't get varicose veins. There are examples where arteries can become aneurysmal, but that's not what we're talking about here. We're talking about low pressure blood returning out of your tissues. And the best analogy I can give somebody is think about this like a root system pulling water into a plant. If you were to take a plant and break away all the dirt, you'd be looking at thousands and thousands of little tiny roots. And that's how our tissues are with veins. You've got these tiny little venules that confluence or join together to make smaller veins, that confluence together to make bigger veins, that ultimately come back towards your heart. And so when blood is returning out of your limbs, let's say like your legs, it's got a long way to go. It's pumping up against gravity. So every time your heart pumps, blood is being pushed forward. And every time your heart is filling and resting between beats, there's a pause, and blood is not moving in those veins. So what happens is the blood is pumping up, and then there's a split second where it can be stagnant and it wants to fall with gravity back down. And our body has a really great system to prevent that. There are these check valves in your veins. Think of it kind of like a little one-way valve. Blood can pump through them, but then as gravity draws that blood back down, they close. And that way blood can kind of march up out of your leg in those pulsatile motions to return blood to your heart. Well, as we age, as you've stood for hours at work, as you've had a pregnancy where a baby sitting in your pelvis is kind of restricting blood flow out of your legs and causing higher venous pressure, those very thin-walled veins can stretch. And when they stretch, all of a sudden those valves don't work as well as they once worked. And so when you have an inefficiency of the blood getting out of your leg, there can be venous stasis, or a longer duration of time where blood is sitting in those veins and that pressure builds to where things stretch, and then it becomes kind of an unfortunate downward spiral. The vein is stretched, it's become less efficient at getting blood out of your leg, so then it becomes more stretched and more inefficient. And as your veins stretch over time, that's how you develop those more tortuous, bulging varicosities. But that kind of breaks down the physiology of varicose veins. What I was hoping to explain is the concept of venous insufficiency, poor venous outflow out of whatever limb we're talking about, in this case generally the legs. So once you combine poor venous outflow, this venous insufficiency, now you start to get varicose veins. And that's where you start to get symptoms. So then the question is, well, how bad are your symptoms? What can we do to treat them? And the treatments start conservatively. We never, ever, ever as surgeons want to jump to surgery as a first line option, because no matter how successful things can be, no matter how generally safe things are, the reality is the things we do can't be undone. That's just the nature of surgery. And so if we don't need to do it, that's a better choice, because there's no risk in not doing it. So the first line of treating venous insufficiency and varicose veins is just behavioral change. If you're doing something that hurts, can you not do that? And I'm not trying to be flippant with that. But if your work requires you to stand, you've got to be there. But if you're at home and your legs hurt, well, could you sit down and put your feet up for ten minutes every few hours? Maybe that would give you some good relief. If that kind of behavior modification doesn't work, the next step would be compression therapy, things that augment the veins. The same idea of these veins being stretched and losing efficiency of those valves. Well, if you can put compression on your whole leg and kind of augment those veins to now sit in a little bit more narrow configuration, maybe those valves will work better. And so if your symptoms are mild, this one little spot on the calf hurts, well, if you wear a compression stocking and it feels better, that's a great endpoint. Maybe nothing more needs to be done. So there are lots of different compression stocking options. What I would tell you is generally the ones that people come to my office with are not as strong as the ones that would be recommended. There's a grading system, millimeters of mercury, of compression strength that we would recommend. And generally something you pick up on Amazon or at Walmart or Walgreens, or maybe you had from another surgery like a TED hose or something, generally doesn't have that grade of compression. So they're not bad to wear, but they might not be adequate. And so a lot of times I'll see people after they've been dealing with this for years. They've been talking to their primary care doctor. Maybe they've been put into compression stockings and maybe they haven't. If you haven't been, that would be the first thing I would say. If you're having symptoms, talk to your primary care doctor about getting some compression stockings graded at maybe twenty to thirty millimeters of mercury compression. Those can be had at a local medical supply store. We've got one here in Spearfish if needed. And the other concept is a lot of times people don't like wearing them, and I can fully understand why. If it's the middle of summer and it's one hundred degrees outside, they're not easy to wear, they're not comfortable to wear. But they generally do help when they're consistently worn. So if you've been given ones and let's say they're knee high and they're not working because maybe you've got veins up in your thigh, they make thigh-high compression stockings. Start with compression stockings that address the area that bothers you. And if it's your whole leg, if you can tolerate it, wear a full-length compression stocking while you're up and about. Not when you're home sleeping, not when you're watching a movie on the couch with your leg raised. But if you're at work standing all day, that's when you want to be wearing it. It's okay to take days off. It's okay to go to a wedding and not wear it that day. But in general, if you're going to commit to seeing will this make it better, I would recommend a good solid period of time, minimum a month, of trying to see if it gets better. As we'll talk about more, a lot of times when insurers go to look at their willingness to pay for intervention, one of the things they'll ask is, have you consistently worn compression stockings as a conservative intervention before they'll authorize an invasive procedure. I'm not an insurance expert by any means, but in general, the most stringent insurance would ask for someone to wear these for three months. Some insurers are much more relaxed. And so that's a concept people need to hear. If you come in to talk about veins and get a plan for how to address them, it is not a snap-your-fingers quick type of process. It generally plays out in the weeks to months time frame, not the hours to days time frame.
And so we talked about the three interventions. When you come to see me and you walk out, generally what I'm going to tell you is, if you haven't worn compression stockings, go home and wear compression stockings, a prescription will be provided if needed. In the meantime, we're going to get an ultrasound to evaluate your legs to see where exactly there is reflux and to what extent. And then with that information, we'll reconvene to talk about the ultrasound, talk about your symptom changes, whether there's been improvement or lack thereof with conservative measures. And then if you're still having symptoms and there's ultrasound evidence of treatable reflux, that's the threshold to say, let's talk about intervening. So kind of let me talk to you about radiofrequency ablation and what that looks like. This is a same-day office procedure where you come in, you've already met me, you've met the nurses, you've gotten your ultrasound, and we've decided to do this. On the morning of, we generally ask you to get up a little earlier, drink a little bit more water than usual, and go for a walk to help your legs engorge with blood. We want your veins to be as prominent as they can be. Just like there's relief from resting and raising your legs, if you get out of bed after sleeping for eight hours and your veins are as small as they've been in a week, and then you rush into clinic, now your veins are much smaller than they were when we saw you for your ultrasound. It can just make the actual procedure a little bit more difficult. So we have you get up, walk around, drink water, help your veins engorge, and then we would see you in clinic. When you get there, there's an ultrasound tech, a nurse in the room, myself, and generally a second nurse to help run and get things if necessary. We would do what we call a pre-scan, just to have the ultrasound tech relook through the leg to make sure we're seeing the same information that was defined on the initial ultrasound. And if that looks consistent with what we expected, we would proceed with the procedure. Generally we start with ablation, where we cannulate or get access to the vein we're treating through a sequence of skin pokes. A needle would access the vein under ultrasound guidance. The ultrasound shows me where the vein is, and a needle can be watched entering the vein directly, so we know it's in the right spot. And then a wire is placed into that needle to gain a pathway that's held into the vein, and then the needle can be removed. But that wire is still in place. And then a small sheath is inserted through the skin that helps dilate or spread the tissues so there's a slightly larger tube accessing the vein, and then through that sheath a treatment catheter can be put in. At the end of the catheter is a small segment that actually heats up. There are different lengths of that segment, but generally a seven-centimeter segment is the typical one that I use. That can be placed up the greater saphenous vein under ultrasound guidance. I'm watching, pushing this treatment catheter up the vein until it's sitting right at the highest extent of that greater saphenous vein, all being watched under ultrasound. When that catheter is in place, we're almost ready to treat the vein. But then what happens next is we need to protect the tissues around the vein. It's literally heating up to a point where it's denaturing the tissue, causing them to be burned in a way where they shrink. And so we don't want all the other tissue around your vein to have that same heat transfer. So there's a solution called tumescent anesthesia. The details aren't really important. What is important is to understand its purpose, and that's to put a fluid around the vein that bathes it in a cool fluid that also doesn't allow heat to quickly transfer to the surrounding tissues. We kind of think of it like a heat sink. If you put a heat sink on a computer chip or something, it dissipates the heat very rapidly and doesn't allow it to accumulate. So the tissue that's touching this catheter heats up, the tissue that surrounds it, think of the water around it so to speak, is not heating up nearly as quickly. So then the fat and the nerves and the skin around the vein don't get injured. And so we walk that heated catheter down the leg in seven-centimeter segments to close the vein. And then once that's done, if there are other large varicose veins, the ropey ones that you can see and feel, then we apply phlebectomy to those. Small incisions are made over those after local anesthetic is injected, and the small portions of the vein are pulled up. The concept is breaking up the continuity of the vessels. We cannot possibly remove every centimeter of vein from your leg, but if there's a prominent pathway, we can remove it and now blood can't flow through it. You're removing segments, trying to get as much of that segment as we can, but the goal is to break up the pathway of blood flow, not to remove every centimeter of vein. Then once we've done the ablation and phlebectomies, we close up any small incisions. The way I do it is with dermabond, basically skin superglue, holding the edges together while it dries. Small bandages are placed over that, and then your leg is wrapped in a combination of a couple different types of compression wrap. There's a Kerlix wrap that I use and then an ace wrap. There are a lot of different ways to do this. I like to use the ace wrap because I think it's easier for patients in the immediate period after the procedure. You can go home the same day. You're awake during the procedure, so it is well tolerated. But I like to be very honest with people. I'm not going to lie to you and say you're not going to feel like you're having something done. If you've been to a dentist, you feel like you're having something done, and it's much the same. We can numb up what we're working on, but I can't take away the sounds. I can't take away the pressure and the pulling and the pushing. And so people are usually very comfortable, but it's not the type of thing where you didn't think anything was happening. There's a reality to it. Ninety-nine percent of the time I do these in my office. In very rare cases, if somebody has a history of extreme anxiety about procedures, or they've got such extensive veins that it's just going to take a really long time, then in rare cases we'll do them in the operating room. But in general I try not to, because it's tolerated well, and that alleviates a huge cost. If we go to the operating room, it's just going to cost a lot more to utilize those facilities.
In the follow-up and recovery period, I would say any procedure you have done, whether it's a vein or a hernia or a gallbladder, there's kind of two ways to think about recovery. There's the immediate recovery, and then there's the more prolonged recovery. The immediate recovery is measured in days. The pain, the achiness, managing bandages, having to not shower for twenty-four to forty-eight hours. Those are things measured in days. And the pain afterward is usually well controlled with Tylenol or ibuprofen. Elevating your leg, resting, but not to a point where you don't do anything. We actually want you to be up and moving around. In general, you can go back to work right away. If your work is very much standing in one place on a concrete floor in a factory or something, maybe take a week off just to let yourself rest. But if your job is more on the desk work side of things, and you have the ability to sit and stand and move around and take a break if you need it, put your leg up, you probably could go back to work the next day, as long as you keep your compression on and have those abilities to elevate your leg. So it is a well-tolerated procedure in the immediate healing window. Now what does it look like? Well, it looks like your leg bruises. Things bruise when we take veins out and make incisions. That bruising and healing isn't going to be gone in two days. Realistically, that's going to be more in that four to six week period before you really can look at your leg and say, all I see are some young, fresh, small stab scars. In those first few weeks, you might have some bruising, you might have some swelling, you might have cord-like feelings in those veins that have closed off and been treated, and that's normal. We are causing the veins to close by injuring them. That's the root explanation. And so those veins healing to a point of being scarred and at their plateau where they're going to be forever, that takes weeks. In that time, you generally are not feeling particularly off or uncomfortable. But again, your leg might be bruised, you might feel that cord in your leg where the treatment took place, and it's going to take a while for it to soften. But the reality is it works. The success rates are very high, in the high nineties. When you look at are we making your reflux symptoms better? Are we making the painful symptomatic varicose veins go away? Yes. So if you look a few months after this procedure, very high, ninety percent are going to say they've had a marked improvement. Now, if you look fifteen years out, are there people that get new varicose veins? Are there people that get recanalization, where veins that were treated maybe open up? Yes, but those numbers are very small. Maybe somewhere in the one to nine percent range. But it's possible. If you're a person that makes varicose veins, if you're a person that has venous reflux, and that combination of a lifestyle that precipitates them and a body that is prone to them, if we treat you now, you're going to have improvement. But if you live another forty years, you're probably going to get another varicose vein. And that's not to be discouraging, but I think it's important to have realistic expectations. If we're coming at this from the point of view of are we making things feel better, are we making the symptoms better, the answer is almost certainly going to be yes. Are we going to make things look perfect to where you say I look like I've never had a varicose vein and I'm never going to get one again? That's probably not a realistic endpoint to expect. So I think I've kind of covered physiology, symptoms, interventions to manage those symptoms, and ultimately the endpoint of intervening with ablation, phlebectomy, and sclerotherapy. I talked a little bit about the recovery. Are there any questions?
So you say that varicose veins are common. So what are we doing as human beings that these valves are not holding up for a lifetime? And is this new? Is this in the last fifty years we've noticed it? Is it getting worse?
So, I mean, there's not going to be a black and white answer here. But the concepts that I think are true are sedentary life. Blood outflow out of our bodies works really well when we move. Our muscles actually help push blood out of our extremities. So if you don't move, blood doesn't move, at least not as well as it could. So you combine sedentary life with weight gain. Weight gain changes our tissues. It changes the amount of tissue that needs blood delivered to it. It changes the shape of our tissues. And so it's not a black and white, it's just weight gain, it's just sedentary lifestyle. But I would say if you look at our culture, our society as a whole, those are probably the two biggest issues. And then you combine it with jobs that don't require us to move. If everybody's job was to hike ten miles a day, I don't think we'd have a lot of these problems. But that's just not the life we live.
So you said for compression socks to wear them effectively, you can wear them at your knee, which I have on some right now, or you can have them up to the thigh. Do they make them like in a tights form? Because I don't know about everyone else, but us big girls, if you wear them up here where you need them, they don't roll down. I need like one of those, you know, things you can attach it.
Yeah, so they do, and it's the most common complaint from patients. They're very hard to keep on. The things that I've heard people have success with are getting ones that have some type of tacky strap, like a tacky upper portion. And then also getting them kind of stretched out so you can actually get them on and have them be tolerable. Something you could do is get a big three-liter pop bottle and roll it down on top of the pop bottle. Let it sit on that overnight when you buy a new one.
Other questions?
This is a little redundant, I think, but the first step is to go to your general practitioner?
So not necessarily. I brought the general practitioner up just because they're the ones patients almost universally see first. If you've been discussing this with your general practitioner and you're seeing them soon, the things you can ask about are, can I get compression stockings? Can I get a referral to see Dr. Czosnyka or a vein specialist? But the bottom line is you don't need that referral. If you want to see myself or Kayla Hatton, the nurse practitioner I work with who oftentimes sees vein consults as the initial consultation, you can just come to see us. In general, a general practitioner is very good at getting a sense of, is this going to be a fruitful visit? Because I don't want you to come and be frustrated when I tell you I don't see anything, I'm ordering you an ultrasound, and the ultrasound didn't show anything. I'm happy to do that workup for you, but sometimes if a general practitioner knows you well, it's just a little bit more easily understood whether this is an appropriate referral. We can see you. I'm happy to see patients without a referral. If you know you've got big varicose veins and you're like, I just don't have a primary care doc and I want to see about just veins, please come and see me. Your primary care doc probably knows you well and so they would be a good first step. But by all means, if you want to be seen in the vein clinic, please come and see us. So compression stockings to try and assess whether or not conservative management will work. Ultrasound is going to be necessary to assess the anatomy and the objective measures of what venous reflux is and whether it's present. And then only if conservative measures fail and there's evidence of reflux that we can intervene on successfully, would you meet criteria for ablation, which is a very successful, very tolerable procedure that will almost certainly give you improvement with very low risk. There are small risks. I didn't quite mention these earlier. Very small risks of things like bleeding at the stab sites, having inflammation and pain along the treatment site, small risk of discoloration of the skin. But that's one of the other reasons that tumescent, that buffer solution, gets put in there, to help push the skin away from the vein being treated so it doesn't have any exposure to the heat. And in the very, very rarest of cases, there are risks of causing blood clots. And how we avoid that is by doing the procedure under ultrasound to avoid treating too close to other veins that could precipitate injuring those veins and causing blood clots. And also following up two days after the procedure with an ultrasound to prove that that hasn't happened. If a blood clot were to form, it almost always forms in an incomplete way, not one that's causing complete obstruction of the venous outflow in your deep veins, but one that might just be a little bit protruding into the pathway of that deep vein from its connection to the vein we treated. And if that's the case, potentially treating it with aspirin for a few weeks in some mild cases, or in some more severe cases true anticoagulation for a month or two. But those are rare, rare complications. And so I wouldn't get too worried about those, but they're something I would discuss with you in a complete consultation.
Thank you so much. That was very, very informative, and it's nice to know we can go directly to you. Thank you all for joining us.